Vallejo, Manuel C. MD; Mandell, Gordon L. MD; Sabo, Daniel P. MD; Ramanathan, Sivam MD
Postdural puncture headache (PDPH) is a well known complication of spinal anesthesia and is often treated with an epidural blood patch (EBP). Factors reported to influence the incidence of PDPH are: age, sex, pregnancy, previous history of PDPH (1), needle size (1,2), needle tip shape (2,3), bevel orientation to the dural fibers (1,4), number of lumbar puncture (LP) attempts (1), midline versus lateral LP approach (5), type of local anesthetic solution (6), and clinical experience of the operator (7).
Table 1 compares the incidence of PDPH among multiple studies. The pencil-point needles are more expensive than the conventional cutting-point (Quincke type) needles. This study compares the PDPH incidence and EBP rates after the use of five different spinal needles in a prospective, blinded, randomized fashion in a busy teaching hospital. Two cutting needles and three pencil-point needles were studied.
After approval from the Magee-Womens Hospital (MWH) investigational review board, informed, written consent was obtained from 1002 women undergoing elective cesarean delivery under spinal anesthesia. All study patients signed a separate research consent form. The study period extended from January, 1993, to December, 1998. We evaluated two cutting needles (26-gauge Atraucan and 25-gauge Quincke), and three noncutting needles (24-gauge Gertie Marx [GM], 24-gauge Sprotte, and 25-gauge Whitacre). MWH is a tertiary care, maternity hospital with more than 8500 deliveries annually. Clinical anesthesia (CA) resident physicians at the CA-II, CA-III, and CA-IV levels performed spinal anesthesia under the supervision of an attending anesthesiologist. By using a computer-generated random number table, the spinal needle for each weekday was chosen randomly, and the name of the spinal needle to be used on that day was posted on the bulletin board. Attending staff and residents used only the selected needle throughout the day for all elective cesarean deliveries.
The Atraucan needle is a double-beveled cutting needle with a sharp first bevel for dural puncture and a second blunt bevel for dilation of the dural hole (Fig. 1). The Quincke needle has a diamond-shaped cutting bevel. Both Atraucan and Quincke needles have a terminal eye (Fig. 1). The Sprotte, GM, and the Whitacre needles are pencil-point needles, and all have lateral eyes. The eye of the Sprotte needle is larger, farther away from the tip, and oval-shaped. The eye of the GM needle is closer to the tip, smaller, and more rounded than the Sprotte needle. The Whitacre needle has a blunter point, and its rectangular eye is situated farther away from the tip than the GM needle (Fig. 1). Both the Sprotte and GM needles are thin-walled.
During the preoperative interview, all study patients were told there was a <5% risk of developing a spinal headache as a result of the procedure. All patients were prophylactically hydrated with 1500 mL of Ringer’s lactate IV before the anesthetic induction. A lumbar puncture was performed at the L2-3, L3-4, or L4-5 intervertebral space with the patient in the sitting position. All patients received a standard spinal anesthetic consisting of bupivacaine 12–14 mg with 8.25% dextrose, fentanyl 25 μg and morphine 0.25 mg. A T4-6 sensory dermatome level was obtained before surgical incision. Maternal age, height, weight, parity, and history of previous PDPH were noted, as well as the type of needle and the operator training level. The cutting needles (Atraucan and Quincke) were introduced with their bevel facing parallel to the direction of the dural fibers. All procedures were closely supervised by a staff anesthesiologist.
Postoperatively, all patients in the study were seen daily by a resident or staff physician unaware of the type of needle used and were questioned for the presence of a headache and any accompanying symptoms such as nausea, vomiting, blurred vision, and tinnitus. A PDPH was defined as an occipital or frontal headache brought on by the erect posture and relieved when the supine posture was assumed. When a patient complained of an occipital or frontal headache, she was monitored daily until she was discharged from the hospital. All patients received a telephone call 1 wk later to evaluate for any signs or symptoms of a delayed-onset headache. Patients with a headache were evaluated for the duration of the headache and their response to treatment. The PDPH was initially treated conservatively with bed rest, hydration, oral analgesics, and/or caffeine sodium benzoate. If the PDPH persisted longer than 24 h with the same severity, an EBP was performed before discharge from the hospital. The decision to perform an EBP was always made by a staff anesthesiologist.
The EBP was performed either by a staff anesthesiologist or by a resident under the supervision of an anesthesiologist. Autologous blood, 15–20 mL, was injected via an epidural needle inserted in the same lumbar intervertebral space where the LP had been performed. The cost of an EBP was obtained from the billing department of the University of Pittsburgh Physicians. The Department of Purchasing of MWH furnished us with the cost of the spinal needles and the epidural trays required to perform an EBP.
Assuming the difference in PDPH incidence between needles to be 3%, an α of 0.05 and a β of 0.8, 200 patients per needle group would be required for each needle to detect this difference. Results were expressed as mean ± 1 sd or median as applicable. Interval data were analyzed by using analysis of variance and nominal data by using contingency table analysis and χ2 test. A P ≤ 0.05 was considered statistically significant.
One thousand two women were recruited. The Atraucan needle was used in 196 women, the Quincke needle in 186 women, the GM needle in 203 women, the Sprotte needle in 214 women, and the Whitacre needle in 203 women. Sixteen patients from the Atraucan group, two patients each from the GM and Whitacre groups, three from the Sprotte group, and 14 from the Quincke group were excluded because of lack of information on bevel orientation, failed or inadequate regional block requiring general anesthesia, and/or technical failures. The data from the remaining 965 patients were used for analysis. The total number of each needle used together with the demographic and obstetric data is presented in Table 2. No differences were noted with respect to age, height, weight, gestation, or history of PDPH (Table 2). The trainees performed, respectively, 83.5%, 75.6%, 85%, 85.9%, and 90.5% of the blocks with the Atraucan, Quincke, GM, Sprotte, and Whitacre needles (Table 3). No differences were noted in the trainee levels among the five needles (Table 3). The staff anesthesiologists used Quincke needles more frequently than other needles (Table 3). No patient had more than two LP attempts. Only 16 patients had two attempts at an LP: 2 in the Atraucan, 4 in the GM, 3 in the Sprotte, 2 in the Whitacre, and 5 in the Quincke groups (P = not significant). Only one patient in the Quincke group who had two attempts at an LP developed a PDPH requiring an EBP. Regardless of the number of attempts at an LP, the anesthesiologists were not allowed to switch to a different needle.
The overall incidence of PDPH in the entire group was 4.6% (44 of 965, power = 0.70), and the overall EBP rate 1.65% (16 of 965). The PDPH incidences, together with EBP rates, are presented in Figure 2. The PDPH incidence and EBP rates were highest in the Quincke group and lowest in the Sprotte group. No patient in the Sprotte and Whitacre groups required an EBP, and one patient in the GM group required an EBP. The PDPH incidence was significantly higher in the Quincke group than the Sprotte and Whitacre groups. The Atraucan PDPH incidence did not show any significant difference compared with the other needles.
The EBP rate was significantly lower in the GM, Sprotte, and Whitacre groups (Fig. 2) compared with the Quincke group, and it was also significantly lower in the Sprotte and Whitacre groups compared with the Atraucan group. All EBPs were performed before discharge from the hospital. Only two patients in the Quincke group required a repeat EBP. In patients with a PDPH, four patients from the Quincke group, one from the Sprotte group, and three from the Whitacre group had photophobia, and one patient from the GM group had tinnitus. All symptoms responded to an EBP. The cost of an epidural blood patch, including the anesthesiologists professional fee, is $520.00, and the price of an epidural tray is $15.00, for a total cost of $535.00.
Our data show that all needles used in our study have the potential to lead to PDPH in obstetric patients. The Quincke needle, introduced with its cutting bevel parallel to the direction of the dural fibers, still results in a higher frequency of PDPH as well as an increased requirement for EBP compared with the three pencil-point needles. Although the Atraucan needle does not result in a statistically higher frequency of PDPH, it does increase the requirement for an EBP compared with the Sprotte and Whitacre needles. This study does not address the issue of backache. We controlled for several variables, including sex, type of procedure, type of local anesthetic, type of approach (midline), and insertion site. In addition, the number of patients with history of PDPH was not significantly different among the five groups of patients. The more frequent use of the Quincke needle by staff anesthesiologists could have been the result of a random occurrence or may be a result of the fact that some staff members elected to perform the LP themselves to avoid possible multiple attempts at LP with a cutting needle by a trainee. The reported Quincke PDPH incidence may have been higher if more trainees had performed the LP.
Several studies have addressed the issue of PDPH with cutting and noncutting needles. These studies are summarized in Table 1. Devcic et al. (8), found no significant difference in PDPH between the pencil-point Sprotte and Quincke needle inserted parallel to the dural fibers in obstetric patients. Their sample size was roughly one-half our study for each needle, and the Quincke needle resulted in 67% more PDPH than the Sprotte needle, although the differences were not statistically significant. Tarkkila et al. (4), who compared the Quincke needle (inserted parallel) and the Sprotte needle, did not find a significant difference between the two needles. However, patients of both sexes were used, and patients had orthopedic and urologic procedures. Mayer et al. (9) could not find a difference between the Quincke and Sprotte needles. However, they used a 27-gauge Quincke in their study. Based on a chart review, Schultz et al. (10) did not find any significant difference between Atraucan and Quincke needles with respect to incidences of PDPH and back pain. Ross et al. (3) noted that the Sprotte needle resulted in a much lower PDPH incidence than the 25- or 26-gauge Quincke needle. They do not state the bevel orientation in their study. Buettner et al. (11) noted a decreased incidence of headache in nonobstetric patients with the Whitacre needle compared with the Quincke needle inserted parallel to the dural fibers. Prager et al. (12) noticed a lower PDPH incidence with the GM and Sprotte needles compared with the Quincke needle (inserted parallel) in patients undergoing myelograms. Kang et al. (13) reported their experience with 26- and 27-gauge Quincke needles in nonobstetric patients in an ambulatory setting.
Although patients from all study groups complained of PDPH, the cutting-needle groups (Atraucan and Quincke) required significantly more EBP than the pencil-point groups. Approximately, 55% and 66% of patients from the Atraucan and the Quincke groups, respectively, required EBP for the treatment of PDPH. In an in vitro study by Morrison et al. (14), the Atraucan needle had a transdural fluid leakage rate comparable to the Sprotte and Whitacre pencil-point needles. However, our clinical results show the Atraucan needle has a significantly higher EBP rate than the pencil-point needles (Fig. 2).
Many factors besides PDPH influence the choice of spinal needle for clinical use. These include ease of insertion, rate of cerebrospinal fluid flow, and the ease with which the needle bends or breaks when excessive forward force is applied. The GM and Sprotte needles are thin-walled and, therefore, may bend more readily than the Quincke needle. However, the thin-walled needles have a faster cerebrospinal fluid return than the conventional thick-walled needles of equal size. Most technical failures (n = 8) in our study occurred with the Atraucan needle.
Pencil-point needles used in our study are more expensive than the Quincke needle (Table 2). However, the choice of a spinal needle must include other cost considerations, such as the cost and side effects of medications used to treat PDPH, the total cost of an EBP, a possible extended hospital stay (12), a visit to the emergency room by the patient, added patient discomfort, and increased staffing requirements.
In conclusion, the pencil-point Sprotte and Whitacre needles are associated with a lower incidence of PDPH compared with the Quincke cutting needle. The GM, Sprotte, and Whitacre needles have a lower EBP rate than the Quincke needle. Compared with the Atraucan needle, the Sprotte and Whitacre needles are associated with a lower EBP rate in obstetric patients. Pencil-point needles should be used for subarachnoid anesthesia in obstetric patients.
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